Cardiac rhythm disorders

Question 1

When in ACLS do you give a precordial thump

Answer 1

When there is no defibrillator in place and you actually witnessed it happen less than 10 minutes ago

Question 2

What are the four conditions where you will not have a pulse

Answer 2

1. ) Asystole
2. ) Ventricular fibrillation
3. ) Ventricular tachycardia
4. ) Pulseless electrical activity

Question 3

What is the treatment for asystole

Answer 3

CPR with epinephrine and atropine

Vasopressin can be used as second agent

Remember epinephrine as restarting the heart, and atropine as bringing up the heart rate. They constrict blood vessels in skin, moving blood to critical organs

Question 4

What is the treatment for ventricular fibrillation

Answer 4

Initial treatment: UNSYNCHRONIZED cardioversion

Then CPR, then defibrillation again, then CPR, then epinephrine or vasopressin, then CPR, then amiodarone or lidocaine with magnesium

Question 5

What is hemodynamic instability defined as

Answer 5

1. ) Chest pain
2. ) Dyspnea/CHF
3. ) Hypotension
4. ) Confusion

Question 6

What is the treatment for ventricular tachycardia

Answer 6

Based on hemodynamic status

1. ) If pulseless VT, then same treatment as defibrillation
2. ) Hemodynamically stable - Start with medications - Amiodarone, then lidocaine, then procainamide, if still unstable, then cardiovert
3. ) Hemodynamically unstable - Start with cardioversions - electrical cardioversion then amiodarone or lidocaine

Question 7

When is unsynchronized cardioversion indicated

Answer 7

Ventricular fibrillation or pulseless VT

Question 8

Which method of giving medications is never indicated

Answer 8

Intracardiac medication

Question 9

What happens if you give unsychronized cardioversion instead of synchronized in VT

Answer 9

May become ventricular fibrillation

Question 10

What is pulseless electrical activity

Answer 10

Heart is normal electrically but not contracting, or it may still be contracting but no blood inside. Either way, no meaningful cardiac output

On exam, person will have normal EKG but no pulse

Question 11

What is the treatment for pulseless electrical activity

Answer 11

Treat underlying cause - either tamponade, tension pneumothorax, pulmonary embolus, potassium disorders, etc

Question 12

When should you consider an atrial arrhythmia

Answer 12

If palpitations, dizzy, exercise intolerance, dyspnea, embolic stroke

Hemodynamic status won’t be compromised

Question 13

Atrial flutter and fibrillation have similar managements. What is the difference between them

Answer 13

Atrial flutter: Regular rhythm - can go back into sinus rhythm or deteriorate into atrial fibrillation

Atrial fibrillation: Irregular rhythm

Question 14

If someone does manage to become hemodynamically unstable from acute atrial arrhythmia, what is the treatment

Answer 14

Synchronized cardioversion - prevents deterioriation into VT or VF

Don’t need anticoagulation prior to this

Question 15

What is the management for chronic Afib

Answer 15

Do not cardiovert this time because this is due to anatomic abnormality and they will merely go back into chronic Afib

Treatment is first rate control: B-blocker, calcium channel blockers, or digoxin

Second treatment is warfarin until INR between 2 and 3 (use heparin if current clot already present)

1. ) Rate control
2. ) Anticoagulate

Question 16

What do you expect for acute atrial fibrillation and chronic

Answer 16

Acute disease normalizes spontaneously, while chronic reverts into arrhythma. So do not cardiovert either

Question 17

What is lone atrial fibrillation

Answer 17

People with Afib but low risk of stroke (i.e. no structural disease causing it), which is determined by

1. ) No cardiomyopathy/CHF/atherosclerosis
2. ) No HTN
3. ) Younger than 75
4. ) No diabetes
5. ) No stroke in past

Question 18

What is the treatment for lone atrial fibrillation

Answer 18

This time anticoagulation is not needed because of unncessary bleeding risk

1. ) Rate control
2. ) aspirin

Question 19

What is the treatment for supraventricular tachycardia

Answer 19

1. ) Vagal maneuvers (carotid massage, valsalva, ice immersion)
2. ) Adenosine second line after vagal maneuvers

Question 20

What is supraventricular tachycardia, and what symptoms does the patient present with

Answer 20

Narrow complex tachycardia without P waves, fibrillatory waves, or flutter waves - caused by a re-entry around AV node

Regular rhythm (distinguish from Afib which looks similar)
No sawtooth appearance (distinguish from Aflutter)

Symptoms: Palpitations

Question 21

What is wolff-parkinson-white syndrome

Answer 21

Anatomic abnormality where there is an accessory conduction pathway from atria to ventricles (no AV node delay so pre-excitation)

On EKG, will see narrow complex tachycardia, short PR interval, and a delta wave (upward deflection before QRS)

Question 22

How will you know if it is wolff parkinson white syndrome, and what is the treatment

Answer 22

SVT alternating with V-tach with delta waves

This gets worse with diltiazem, verapamil (calcium channel blockers) and digoxin because they accelerate conduction through accessory pathway

Medications: Procainamide and amiodarone
Cure: Radiofrequency catheter ablation

Question 23

What is the most accurate test for wolff parkinson white syndrome

Answer 23

Electrophysiologic studies which will show where the anatomic defect is located

Question 24

What is multifocal atrial tachycardia and treatment

Answer 24

3 different P-wave morphologies associated with COPD

Treat underlying cause, treat as Afib, and do not give beta blockers because of lung disease

Question 25

If someone presents with bradycardia, what is the first thing you must do

Answer 25

EKG - must rule out that something else is not going on, otherwise if there is nothing then just reassurance is needed

Question 26

If someone presents with bradycardia and is symptomatic (i.e. hypoperfusion) what is the treatment

Answer 26

Best initial therapy: Atropine

Most effective therapy: Pacemaker

If no symptoms, then do nothing after getting EKG